Basic Information
| Provider Information | |||||||||
| NPI: | 1881252286 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FAIRVIEW HOSPITAL | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | EAST MOUNTAIN MEDICAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1728 | ||||||||
| Address2: | |||||||||
| City: | PITTSFIELD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 012021728 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4134473003 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 780 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | GREAT BARRINGTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 012302148 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4135288643 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/31/2019 | ||||||||
| LastUpdateDate: | 02/12/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | RODOWICZ | ||||||||
| AuthorizedOfficialFirstName: | DARLENE | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 4134473003 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | FAIRVIEW HOSPITAL | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/12/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
No ID Information.